The intent of BadgerCare Plus's brand medically necessary policy is to ensure that brand name drugs are being prescribed appropriately when generic equivalent drugs are available. The policy described in this BadgerCare Plus Update is effective for prior authorization (PA) requests received on and after July 1, 2008.

All brand medically necessary PA requests are reviewed by a pharmacist to ensure that medical necessity requirements for brand name drugs are met. The pharmacist reviews the member's profile of pharmacy claims reimbursed by BadgerCare Plus along with the supporting PA documentation submitted by the prescriber.

In most circumstances, it will be necessary for a member to try more than one generic equivalent drug before a brand medically necessary PA request may be approved by BadgerCare Plus.

To demonstrate the medical necessity of a brand name drug, the PA request must include documentation about how the generic equivalent drug(s) failed to achieve the desired treatment outcome and why the brand name drug is expected to achieve the desired outcome. Prescribers should document on the PA request the specific details about the previous treatment results with generic equivalent drugs, including the generic equivalent drugs that the member tried.

The Preferred Drug List (PDL) policy regarding non-preferred drugs also applies to brand medically necessary PA requests. For example, a prescriber writes a prescription for a brand name drug. The generic drug is currently a non-preferred drug on the PDL. Before a PA request may be approved for the brand name drug, trial and failure of multiple PDL preferred drugs is required. When a drug is a generic non-preferred drug on the PDL, trial and failure of multiple preferred drugs is required before a PA request may be approved for a brand name drug.

Prior Authorization Requests

For PA requests for brand medically necessary drugs, prescribers are required to complete and submit to the pharmacy the Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA), HCF 11083 (fillable PDF, 312 KB) (07/08), and the prescription with "Brand Medically Necessary" handwritten on it. The prescriber should also submit to the pharmacy all of the appropriate supporting documentation. The pharmacy provider then completes a Prior Authorization/Request Form (PA/RF), HCF 11018 (10/03), and submits to BadgerCare Plus the following:

• A completed PA/BMNA from the prescriber.
• Supporting documentation submitted by the prescriber. (The PA request must include sufficient supporting documentation for a pharmacist consultant to make a determination about the request.)
• A copy of the prescription with "Brand Medically Necessary" handwritten on it.
• A completed PA/RF.

Effective for PA requests received by BadgerCare Plus on and after July 1, 2008, prescribers are required to submit the revised PA/BMNA for brand medically necessary drugs. Prior authorization requests received on a PA/BMNA, dated 03/05, will be returned. Providers may continue to submit the existing PA/BMNA for brand medically necessary drug PA requests received on or before July 1, 2008. Refer to Attachment 1 (PDF, 92 KB) and Attachment 2 (fillable PDF, 312 KB) of this Update for the revised PA/BMNA completion instructions and form.

Prescribers are required to hand write “Brand Medically Necessary” on each prescription for a brand name drug. Pharmacy providers are required to submit a copy of the prescription with the PA request to BadgerCare Plus.

As a reminder, a PA request may be authorized for a maximum period of up to one year. A new PA request does not need to be resubmitted with each prescription refill. When a PA request is approved, the provider is required to indicate the PA number on claim submissions. The claim will be denied if the PA number is not indicated on the claim. New PA requests submitted after a PA request expires must include all documentation supporting the medical necessity of the brand name drug, even if it is a new request for a previously approved brand medically necessary PA.

Approval Criteria

The prescriber is required to document why it is medically necessary for the member to receive the brand name drug on the PA/BMNA. Criteria for approval of a PA request for a brand medically necessary drug include any one of the following:

• Treatment failure(s) with the generic equivalent drug(s).
• Clinically significant adverse drug reaction(s) to the generic equivalent drug(s).
• Allergic reaction(s) to the generic equivalent drug(s).
• A medical condition that causes a contraindication to the use of the generic equivalent drug(s).

Narrow Therapeutic Index Drugs

The clinical criteria for approval of a PA request for a narrow therapeutic index (NTI) drug include the prescriber’s documentation of an anticipated treatment failure of one of the following generic NTI drugs:

Brand name anticonvulsant drugs used for the treatment of seizure disorders.

• Clozaril.
• Coumadin.
• Neoral.
• Prograf.

Providers are reminded to document the anticipated therapeutic failure of a generic NTI drug in the member’s medical record.

Documentation Requirements

BadgerCare Plus must receive adequate documentation on the PA/BMNA or attached to the PA request for the pharmacist consultant to make a determination about the request. The following are documentation requirements for PA requests for brand name drugs.

The prescriber should indicate specific details on the PA/BMNA about the previous treatment(s) with generic equivalent drugs, including the dose of medication and the approximate dates the generic equivalent drugs were taken. For each previous treatment with a generic equivalent drug, documentation on the PA/BMNA should include, but not be limited to, the following:

• Detailed documentation about the adverse drug reaction(s), allergic drug reaction(s), or treatment failure(s), including why the use of the brand name drug will prevent recurrence and achieve the desired treatment outcome.
• The duration and approximate dates of the previous treatment(s).
• The dose of medication that was taken.
• The indication for use, either a diagnosis code or diagnosis description.
• A description of the medical condition that causes a contraindication to the use of the generic equivalent drug(s).

If a member experienced a treatment failure while taking generic equivalent drugs, the prescriber should include specific details on the PA/BMNA about the treatment failure(s), as well as how the brand name drug could resolve the issue.

While the specific details indicated above may not apply to all brand medically necessary PA requests, the provider is required to indicate complete and comprehensive documentation on the PA/BMNA.

Prescribers are reminded to also document adverse drug reaction or treatment failure information completely and accurately in the member’s medical record.

For More Information

Providers may refer to the April 2005 Update (2005-24), titled "Expanded Brand Medically Necessary Prior Authorization Criteria," for additional information about brand medically necessary policy requirements.

Information Regarding Managed Care

This Update contains fee-for-service policy and applies to services members receive on a fee-for-service basis only. For managed care policy, contact the appropriate managed care organization. BadgerCare Plus HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment 1 — Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) Completion Instructions (PDF, 92 KB)
Attachment 2 — Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) (fillable PDF, 312 KB) | Word (71 KB)